Today we received the results of his assessment, and they are as follows:
Joshua has Cerebral Palsy (diagnosed at 13 months) secondary to Hypoxic Ischaemic Encephalothy and secondary microcephaly. He has Spastic Hemiplegia (GMFCS Level II) affecting predominantly the Right upper and lower limb (with some involvement of his left side), and global developmental delays.
Joshua has been seen by a number of Allied Health services in the past, and is currently a client of Carpentaria Disability Services – Early Intervention Services (CDS-EIS) where he attends a weekly therapy session (fortnightly from July 2014), and Private Physiotherapist Phil Sutherland of Moil Physiotherapy (monthly). His Paediatrician is Dr Peter Morris of Royal Darwin Hospital. Joshua is regularly reviewed by the Visiting Paediatric Rehabilitation Service (Adelaide Women’s & Children’s Hospital), with his next review scheduled for October 2014.
Joshua had serial casting for his Right leg in December 2013, and wears an AFO.
Joshua attends childcare 3 days/week, and recently moved to a new Childcare Centre, which includes a preschool program. Karissa is considering transitioning Joshua to the preschool program in the second half of this year, with enrolment in a full preschool program in 2015 (school still to be decided).
Karissa reported that Hearing was last tested in 2011, with results showing adequate hearing for speech & language development. Vision was assessed in January 2012, with results indicating no concerns. A recommendation was made that Joshua have his vision checked prior to starting school.
The following information regarding Joshua’s communication and play skills was provided by Speech Pathologist Gabrielle Kelly of Carpentaria Early Intervention Services in May 2014:
- Communication - Comprehension: currently working on early concepts (wet, out, off) and possession words (my, mine, your)
- Communication – Expression: Using 1-2 word phrases such as “down there”, and has a number of favourite words/phrases that he uses.
- Augmentative & Alternative Communication (AAC) - Have commenced using PODD (Pragmatic Organisation Dynamic Display) Communication Book – a multi-level communication book, with words and symbols arranged in a systematic way.
- Now able to stay at one play idea for extended periods, enjoys some basic pretend play (home themes such as bathing baby), and play sequences up to 5 steps with encouragement.
- Needs support to sequence the steps to an activity, will leave the activity when challenging; sequences need to be slowed down and broken down into achievable steps.
- Requires space/pauses/waiting time to think, process, sequence and respond
- Have commenced work on speech sounds.
Recent Physiotherapy Gross Motor goals include: R foot tap, squatting with best possible symmetry, single leg balance, catching, bike riding (feet strapped to pedals), and investigation of suitable seating to assist floor sitting.
Further details regarding Joshua’s musculo-skeletal status and gross motor function are available in the CDS-EIS Referral Letter to private Physiotherapy Provider February 2014.
Self Help including Dressing Skills
OCCUPATIONAL THERAPY ASSESSMENT
Joshua was assessed over two occasions at the OT for Kids NT clinic. He attended with his mother Karissa and younger sister Amelie aged 2.
Joshua presented as friendly, curious and active. He found it difficult to attend to tasks for long periods and was easily distracted, but cooperated to the best of his ability with prompts and encouragement.
Selected sections/tasks of the following assessments were used as appropriate:
Play based observations
Sensory Processing Measure- Preschool (SPM) Home Form
Symbolic & Imaginative Play Developmental Checklist (SIP-DC) + parent report
Kidscreen Occupational Therapy Profile 18 months – 3 years, 3 – 6 Years
Cerebral Palsy Upper Limb Assessments
Assessment: Observations, general impressions & parent report
Joshua sits in an asymmetrical W-sitting position, which Karissa reports is not usually corrected, as he is quite active and hip surveillance results have so far been normal. He is not able to sit stably in cross-legged sitting, or in long sitting without support. He can be encouraged to sit in a semi side-sitting posture.
During assessment Joshua communicated by simple gesture, other non-verbal strategies such as facial expression and eye contact, and the occasional single word such as “No”. He presented as a willing communicator who was able to get his message across; he interacted well with the therapist by holding things up in front of her to show or request that she do something. He often required gesture, demonstration and repetition in order to understand instructions.
Joshua enjoyed repetition of simple games such as a “rocket” game where the therapist held both Joshua’s hands around a wooden stick and flew them up in the air and around like a rocket. He appeared to get “stuck” on some activities, for example he wanted to repeatedly knock a block tower down rather than try to build it as high as he could. He also tended to imitate his younger sister, especially with activities that were not allowed, such as crawling under the table and playing with the window blinds.
Joshua presented with limited play skills for his age – for example he put the whole toy cup in his mouth rather than pretend to drink from it, and no constructive or imaginative play was observed. Towards the end of the session Joshua tended to throw toy items over his shoulder rather than play with them more constructively.
Joshua frequently mouths, licks or puts objects into his mouth. He also uses his mouth to manipulate objects – for example holds the item in his mouth to allow him to re-position it in his hand. Joshua had some difficulty with saliva management, with some drooling noted at times.
Joshua tended to ask for help or give the item to an adult when having difficulty, however he could be encouraged to persevere with support.
Socially Joshua’s mother reported (via the SPM) that Joshua is still learning to: play with friends cooperatively, share things when asked, join in play without disrupting it, participate appropriately in family outings or activities with friends, and cooperate during family errands such as shopping.
Assessment: Upper Limb Assessment & visual function – informal tasks with reference to Cerebral Palsy Upper Limb Assessments
Result: impaired skills in line with diagnosis, but good functional ability
MACS (Manual Ability Classification System for Children with Cerebral Palsy 4 – 18 years) – likely Level II: Handles most objects but with somewhat reduced quality and/or speed of achievement.
RIGHT UPPER LIMB AND BILATERAL SKILLS:
- Spontaneous bilateral use of hands together eg. to open containers, large bead threading and maintaining grasp as required
- Good transfer of objects hand to hand.
- Able to bring hands together in midline eg. to squash playdoh
- Functional grasp using the R hand – able to open hand and fingers/thumb fully to grasp a container, and able to maintain a firm hold on the container eg holding the playdough container while getting the playdoh out with the other hand.
- R pincer grasp – inconsistent spontaneous use of a crude pincer to pick up small items, however was unable to then use this grasp functionally, such as re-orienting/ manipulating the small item in this hand.
- Transfers small items to his L hand when precision or manipulation is required, for example to place it in a hole.
- Had some difficulty reproducing spontaneous actions on request – for example when asked to again use a basic pincer grasp he tried to use a whole hand grasp; this could indicate motor planning difficulties.
- Always reaches across with his L hand to pick up an item on his right side during spontaneous movement, however with encouragement will reach for an item with his R hand.
- Orients activities to his left side, or turns his body to the right to perform tasks.
- Difficulty using two hands together in coordinated motion eg. to roll a playdoh snake.
LEFT UPPER LIMB SKILLS:
While Joshua has good function of his Left (less-affected) hand, some reduced skill for age is noted – for example:
- held a knife awkwardly and needed hand-over-hand assistance to help him re-position to enable cutting.
- lack of precise pincer grasp and in-hand manipulation– for example had difficulty imitating a tripod grasp action (“crab fingers”); this may also be related to a motor planning difficulty.
Joshua had difficulty with smooth and consistent follow of a moving object with his eyes, visually locating objects, changing his visual focus from one object to another, and keeping his head still while just moving his eyes. He was generally was slower with these tasks, but could achieve them with time and encouragement. Difficulty with visual movements is likely impacted by impaired motor control (head and eye movements), reduced motor planning, and reduced visual and general attention.
Joshua had some difficulty with visual attention, needing occasional reminders to look at what he was doing; he was also easily distracted by other items in the room.
RANGE OF MOVEMENT (ROM), MUSCLE TONE & STRENGTH, and SENSATION:
Difficult to formally assess as Joshua was resistant to handling by the therapist, however the following is noted:
- Increased tone of the R upper limb with shoulder retraction and elbow flexion when doing unilateral tasks with the other hand.
- Slight-moderate decrease in Active ROM at R shoulder and elbow when raising arms high.
- Full Passive ROM of the R upper limb at the elbow has been noted in previous assessments.
Upper Limb muscle tone, strength, range of movement & sensation can be further assessed and monitored as required during therapy sessions.
Assessment: Sensory Processing Measure - Home Form
Comments: Results indicate that sensory processing factors that may be impacting on Joshua’s performance of daily tasks, with the main features as follows - Joshua:
Is over-responsive (more sensitive) to visual input – for example he has trouble paying attention/completing tasks if there are a lot of things to look at, is bothered by busy visual environments, & becomes easily distracted by looking at things while walking. However he also seek visual input (enjoys watching objects spin & move, flips light switches on and off repeatedly).
Is also occasionally over-responsive to auditory input, for example is easily distracted by background noises, responds negatively to loud noises.
Seeks oral sensory input for example by tasting non-food items.
Seeks intense input (body awareness feedback) from muscles and joints for example seems driven to seek activities such as pushing/pulling/dragging/jumping; chews on toys, clothes, or other objects, seems to enjoy sensations such as crashing on the floor.
Has difficulty with postural control, as expected for his diagnosis - for example he leans on other people/furniture when sitting or trying to stand up, and has poor coordination. While Joshua is very active and enjoys movement activities, he is also occasionally fearful of some movements such as going up/down stairs, or using swings, slides and other playground equipment.
Has difficulty with Ideation (the ability to create a concept or mental image of a new task), for example tends to play the same activities over and over. Has occasional difficulty with motor planning, such as gets confused about the proper sequence of actions for everyday routines, difficulty completing tasks with multiple steps, difficulty imitating demonstrated actions eg. movement games /songs.
Assessment: Kidscreen Occupational Therapy Profile
Result: Significantly delayed fine motor, visual perceptual and concept skills for age.
Joshua’s performance was likely influenced by his difficulty understanding some task requests, his reduced attention, and his sequencing/planning difficulties.
Joshua is able to:
Insert a wooden dowel “needle” into large wooden beads but had difficulty pulling the string through
Unscrew a lid with some assistance
Build a tower of 6 blocks
Use two hands to open and close scissors but not cut
Take stacking rings off and put some back on (not in size order)
Do circular and back-and-forth scribble using a crayon
Roughly imitate vertical and horizontal lines, and circular scribble (imitation of a circle) with repetition and prompting
Use a L digital-pronate grasp to hold the crayon while drawing
Place pegs into a pegboard
Joshua had difficulty or is unable to:
Match photos or pictures without support/prompting
Make snips in paper with scissors held in one hand
Imitate simple 4-block designs
Imitate simple body postures without prompts
Put stacking rings back in size order
Identify the big one from a choice of two items
Complete a 4-piece formboard or 2-3 piece puzzle (difficulty with selecting correct piece, using small movements to make the piece fit, and perseverance)
Put 2 halves of a toy (wooden fish) together.
Imitate a circular stroke, copy a horizontal or vertical line
Assessment: Self Care skills – information from parent
Result: delayed for age
Toiletting: not yet toilet trained, and is not showing signs of awareness or readiness – although will now say the words “wee” and “poo”
Mealtimes: feeds himself with a spoon and has started using a fork to stab and pick up food; is unable to spread with a knife – instead he stabs the knife around.
Dressing: requires assistance
Joshua is an energetic, engaging and curious boy who presents with significant delays across a number of developmental areas, but good function and participation within these difficulties. He enjoys movement and is willing to attempt most activities with enthusiasm!
Along with his communication and gross motor delays, Joshua has:
- Poor sitting posture (in particular for floor sitting) which together with reduced balance and postural control, impacts on his performance of skilled tasks.
- Slightly impaired use of his right upper limb and to a lesser extent his left upper limb as well as bilateral skills, but functionally manages well at this stage of his development
- Delayed fine motor skills – including for drawing/prewriting, cutting, manipulation and skilled bilateral tasks.
- Delayed visual-perceptual (puzzles, picture & object matching, sorting like objects) and concept skills (size, colour, shape) for his age
- Limited attention and is easily distracted
In addition, Joshua has some sensory needs which impact on his daily performance. In particular his over-sensitivity to visual and to a lesser extent auditory input leads to him being easily distracted; his need for feedback about his body (proprioceptive input) leads to him seeking out intense movement activities such as jumping, crashing and chewing on non-food items; his need for oral sensory input leads to him tasting/chewing non-food items; and his reduced postural control impacts on his performance of skilled movement tasks.
Joshua is sure to enjoy preschool but will require a high level of support and curriculum adjustment in preschool and beyond, in order to maximize his learning potential.
1. Individual OT sessions in order to develop skills in identified goal areas:
a) Preschool Skills – a range of fine motor, visual perceptual and concept skills, as well as on-task behaviours such as attention and task completion
b) Bilateral upper limb skills including fine motor skills
d) Self Help including Dressing Skills
These sessions can also incorporate work on sequencing and motor planning.
2. Provide opportunities at home and childcare/preschool to meet Joshua’s sensory needs:
a) Body feedback/”heavy” movement activities (these activities will als0 improve body awareness & postural control) – using attached Proprioception activities handout.
b) Targeted visual activities - to help teach visual discrimination (simple treasure hunts, find the hidden object, what’s different) and visual tracking (ideas can be supplied), as well as ensuring that visual stimulation is limited or reduced when attention to task is required.
c) Meet oral sensory/proprioception (through the jaw) needs by offering chewy food, drinks through a straw (including thick liquids such as smoothies); offer acceptable alternatives (eg. a chewy bracelet or toy) when Joshua puts a non-food item into his mouth.
3. Trial and prescribe seating and other equipment as required for preschool and home. Discourage W-sitting where possible via provision of alternative seating positions; continue to work on improving floor sitting position including investigation and provision of seating, in conjunction with treating Physiotherapist.
4. Referral to Education Advisors, Early Childhood Intervention (School Support Services, Dep’t of Education) – for further assessment, assistance with preschool placement, and support (This was actioned following initial assessment)
5. Ongoing liaison with other service providers (Private Physiotherapy, CDS-EIS, Education Advisors ECI) as required.
6. Childcare/Preschool recommendations:
a) Discourage W-sitting where possible; provide alternatives such as Joshua to use his “long sitting” chair at preschool/childcare when sitting on the floor.
b) Meet oral sensory/proprioception needs by offering chewy food, drinks through a straw (including thick liquids such as smoothies); offer acceptable chewable alternatives (eg. a chewy toy or bracelet) when Joshua puts a non-food item into his mouth.
c) Provide lots of opportunities for movement and body awareness (proprioceptive) activities.